Mental health advocates question Kansas ‘step therapy’ bill

TOPEKA — Mental health advocates are raising concerns about a bill passed by Kansas lawmakers that would require doctors to try cheaper drugs before more expensive ones for Medicaid recipients, but the bill's backers say the concerns are overblown.

The process, called step therapy, is common in many private and public health insurance plans. It was key to resolving budget issues because it would reduce the state's cost of providing health care for poor residents by nearly $11 million a year. Gov. Sam Brownback is expected to sign the bill Monday.

Mental health advocates asked that drugs used to treat mental illnesses be specifically exempted on the grounds that the process of trial and error with them would have more severe consequences, including a greater risk of hospitalization and suicide, than with drugs that treat other conditions.

People have different responses and tolerance levels with psychiatric drugs, said Rick Cagan, executive director of the Kansas affiliate of the National Alliance on Mental Illness.

"Individuals and their prescribers need to have the greatest degree of flexibility to ensure a good match for patients," Cagan said. "We don't know as much about how the brain responds to this whole kind of cadre of medications ... as we do with cardiac and other kinds of medications."

But lawmakers who supported the bill say adequate safeguards are in place and mental health advocates want an unfair exemption from a common practice that many insured patients face.

"They just want to be left totally outside so that they don't have to do anything like the rest of the world has to do," said Republican Sen. Jim Denning, of Overland Park. "If a new patient comes into the system, they will be given the right drug or combination of drugs to keep them as healthy and as well as we can."

One issue is how much protection is offered by an oversight group set up to provide input from mental health clinical professionals in the creation of mental health drug regulations.

Lawmakers assured their colleagues during debates in both chambers that mental health patients would be safeguarded by a measure passed last year. The law allows insurance companies to require prior authorization for certain mental health drugs for Medicaid recipients, but it also created a nine-member committee of mental health practitioners and pharmacists who offer recommendations to a state drug review board. The board decides whether to accept the committee's recommendations on prescription drug use. For example, the committee recently reviewed dosing limits for children's antipsychotics.

The committee was created to address safety issues, but Amy Campbell, lobbyist for the Kansas Mental Health Coalition, worries that under this year's bill the committee will be asked to recommend blocking access to medication because of cost. The issue is worsened for mental health patients because new anti-psychotic drugs tend to be expensive, she said.

Another concern is whether mental health patients will be able to navigate administrative hurdles if they're turned away from a pharmacy because the drug their doctor ordered was too expensive, Campbell said.

"For someone who doesn't own their own transportation, who may or may not have strong cognitive abilities ... our biggest fear is that they will walk out of the pharmacy and they don't come back for the adjustments to be made," she said.

Some psychiatrists are also concerned that step therapy will pose a hassle for doctors, who will have to spend more time justifying treatment.

"That's time that they can't be spending seeing patients who are already having a hard time getting into places," said Dr. Taylor Porter, a Topeka psychiatrist and a member of the Mental Health Medication Advisory Committee. Most Medicaid recipients visit busy mental health centers because many physicians and clinics don't accept Medicaid, he said.